SPEX Internal Medicine 4 — Questions and Answers
Question 1: A 60-year-old man presents with progressive dysphagia, weight loss, and a barium swallow showing a 'bird's beak' appearance of the distal esophagus. What is the most likely diagnosis?
- Esophageal squamous cell carcinoma
- Achalasia (Correct answer)
- Diffuse esophageal spasm
- Zenker's diverticulum
Correct answer: Achalasia
Achalasia presents with dysphagia to solids and liquids, regurgitation, and the classic 'bird's beak' tapering on barium swallow due to failure of LES relaxation.
Question 2: A 35-year-old woman presents with fatigue, arthralgias, and jaundice. Labs show AST 480 U/L, ALT 520 U/L, ANA 1:640, and anti-smooth muscle antibody positive. What is the most likely diagnosis?
- Primary biliary cholangitis
- Autoimmune hepatitis (Correct answer)
- Wilson's disease
- Non-alcoholic fatty liver disease
Correct answer: Autoimmune hepatitis
Autoimmune hepatitis is characterized by elevated transaminases, positive ANA and anti-smooth muscle antibodies, and responds to immunosuppressive therapy.
Question 3: A 78-year-old man with atrial fibrillation presents with an acute, painful, pulseless lower extremity. Doppler shows absent signals below the popliteal artery. What is the MOST appropriate next step?
- Immediate anticoagulation with heparin and urgent vascular surgery consult (Correct answer)
- CT angiography of the pelvis and lower extremities before any intervention
- Thrombolysis with tPA alone
- Compression stockings and outpatient follow-up
Correct answer: Immediate anticoagulation with heparin and urgent vascular surgery consult
Acute limb ischemia requires emergent anticoagulation to prevent clot propagation and urgent surgical or endovascular revascularization within hours to save the limb.
Question 4: A patient with long-standing type 1 diabetes develops orthostatic hypotension, early satiety, nausea, and vomiting. A gastric emptying study shows delayed gastric emptying. What is the first-line pharmacological treatment?
- Ondansetron
- Metoclopramide (Correct answer)
- Erythromycin
- Domperidone
Correct answer: Metoclopramide
Metoclopramide is the only FDA-approved medication for diabetic gastroparesis, acting as a dopamine antagonist and prokinetic agent.
Question 5: A 52-year-old woman with no prior cardiac history is found to have a troponin I of 2.8 ng/mL, new ST depressions in leads V4–V6, and chest pain at rest. What is the most appropriate management?
- Discharge with aspirin and outpatient stress test
- Admit, anticoagulate, and perform early invasive strategy (coronary angiography within 24–72 h) (Correct answer)
- Immediate thrombolysis with alteplase
- Echocardiogram and outpatient follow-up in 2 weeks
Correct answer: Admit, anticoagulate, and perform early invasive strategy (coronary angiography within 24–72 h)
Non-ST elevation MI (NSTEMI) with elevated troponin and ischemic ECG changes warrants hospital admission, anticoagulation, and early invasive angiography per guidelines.
Question 6: A 44-year-old man presents with severe acute pancreatitis. On day 3, his Ranson's criteria score is 5. Which complication should be most anticipated in the next 48 hours?
- Pancreatic pseudocyst formation
- Respiratory failure from ARDS or pleural effusion (Correct answer)
- Peptic ulcer perforation
- Aortic dissection
Correct answer: Respiratory failure from ARDS or pleural effusion
Severe pancreatitis (Ranson's ≥3) carries high risk of systemic complications including ARDS, respiratory failure, pleural effusions, and multi-organ dysfunction.
Question 7: A 68-year-old woman with newly diagnosed multiple myeloma has serum calcium of 12.8 mg/dL, creatinine 2.0 mg/dL, hemoglobin 8.2 g/dL, and lytic bone lesions. Which of the following is the best initial treatment for her hypercalcemia?
- Furosemide diuresis
- IV normal saline hydration plus zoledronic acid (Correct answer)
- Oral calcium restriction alone
- Dialysis
Correct answer: IV normal saline hydration plus zoledronic acid
IV hydration is the first step in managing hypercalcemia; bisphosphonates (zoledronic acid) are added for malignancy-related hypercalcemia and also protect bone.
SPEX Internal Medicine 4
A 60-year-old man presents with progressive dysphagia, weight loss, and a barium swallow showing a 'bird's beak' appearance of the distal esophagus.
What is the most likely diagnosis?